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In this article Robert E. McAfee of the American Medical Association (AMA) discusses domestic violence as a womens health issue. He notes that over the past 20 years violence has become a more urgent and visible public health problem in the US. It is considered a national epidemic and a major public health problem that has a strong gender base. Domestic violence is also identified by health care professions with the same concern for diagnosis referral treatment and prevention as they would any public health problem. In response the AMA has been working to elevate the issue of family violence to one of a public health concern; and to arm all physicians with the information they need to begin to understand how they can help. The Association is also striving to get a more rational gun ownership law in the US as part of its effort to minimize and eliminate the problems of violence in the home and in the workplace.

I have had the opportunity to address many different audiences—both inside and outside the federation—and I have told many audiences how happy I was to be in this place or that, but I can't begin to tell you how honored I am to stand before you tonight, surrounded by so many familiar faces. It is a moment for the poets. Robert Frost writes, Two roads diverged in a wood, and I— I took the one less traveled by, And that has made all the difference. Frost's poem is about the choices that we make: what we choose, how we choose, and why we choose. But if the poem is about choosing, it is also about character. Something impels the poet to choose the road less traveled, just as something inside each of us in this room has impelled us to pursue the endless frontier that is medicine. Why did we

An obviously well-to-do older woman goes for her yearly physical examination. Her physician asked during the routine history, in a nonpejorative fashion, "Has anyone harmed you in the last year? Do you feel safe at home?" Much to the physician's surprise, she sighs, responding, "Nobody has ever asked me that before. I thought I was hiding it better." Language: en

During the past 4 years, the American Medical Association (AMA) has made diagnosis and prevention of family violence one of its top public health priorities. The AMA's definition of family violence includes child physical abuse, child sexual abuse, domestic violence or spousal abuse, and elder abuse as the four components—together a major public health problem. While previous AMA policies have sought to deter aspects of family violence, no concerted effort was made until a presentation at the AMA National Leadership Conference by the Board of Trustees in 1991. The overwhelming effect of that presentation led to a survey on the extent of domestic violence and the proper way to control it. 1 Among the findings: Three fourths of all Americans see violence as a very serious problem, and 40% believe family violence is a very serious problem in this country. More than 85% of Americans felt they could tell a

In Reply. —Dr Tyson is correct in identifying that medical costs associated with family violence, which includes domestic violence, child abuse, and elder abuse, represent a staggering and impressive part of the total health bill of the United States. It is important that such costs be identified and that all participants, including insurance companies, assist in preventive and educational efforts to minimize this cost. The program described by Tyson appears to be this kind of program, and he and the Pennsylvania Blue Shield Institute need to be congratulated. I am further heartened that Tyson agreed with the need to eliminate discrimination in the insurance industry for victims of family violence. Certainly, those instances in which an attempt either not to insure or to increase substantially the rate for individuals identified as victims of family violence seem inappropriate and even actuarially questionable. In July 1995, Timothy Flaherty, MD, an AMA trustee

There is a massive body of evidence, derived from many scientific disciplines, that tobacco is addictive and kills smokers. Up to half of those who continue to smoke cigarettes will die prematurely from diseases caused by smoking, half of these deaths occurring in middle age. 1 Peto et al 2 have calculated that of the 1.25 billion people now living in developed countries, 250 million will, if present tobacco consumption patterns are maintained, die from tobacco. With 3 million deaths worldwide each year currently due to tobacco use, the consequences of tobacco to the public health have been, and will continue to be, staggering, and the importance of bringing this hazard under control is correspondingly great. It is against this background that JAMA publishes several highly unusual articles this week. The Documents On May 12, 1994, Stanton A. Glantz, PhD, a professor of medicine in the Division of Cardiology at

Following the approval of the long-acting contraceptive levonorgestrel (the Norplant Contraceptive System) for use by women, government officials have requi-ed or proposed uses of levonorgestrel that are problematic. One court ordered a woman convicted of child abuse to use levonorgestrel as a condition of her probation; legislators have proposed that women on welfare be paid to use levonorgestrel. Court-ordered use of long-acting contraceptives because of child abuse raises serious questions about a person's fundamental rights to refuse medical treatment, to be free of cruel and unusual punishment, and to procreate. The state's compelling interest in protecting children from abuse may be served by less intrusive means than imposing contraception on parents who have committed child abuse. If government benefits were based on the use of long-acting contraceptives, individuals would have to assume a potentially serious health risk before receiving their benefits. Government benefits should not be made contingent on the acceptance of a health risk. ( JAMA . 1992;267:1818-1821)

A successful primary repair of a fistula between the proximal aortic suture line and duodenum was performed in a 47-year-old man with the use of a saphenous vein patch graft with omental interposition between the aortic repair and the duodenum. Massive local and parenteral antibiotics were given. The patient remains completely well 3 1/2 years later.

• Gas within the hepatic venous system on abdominal roentgenogram prompted exploratory laparotomy in a patient with repeated rigors and high fever following total hip replacement. Although the patient had no localizing abdominal symptoms or signs, an intra-abdominal abscess was found and cured by surgical drainage and antibiotics. Occult, life-threatening, but treatable abdominal disease may be detected by the unusual roentgenographic finding of portal venous gas. (Arch Intern Med1982;142:1725-1726)

For over 30 years, the American Medical Association (AMA) through its policies, programs, and publications has continued to alert the public to the medical consequences of the use of tobacco. This issue of JAMA , the third issue devoted to the problem of smoking, signifies the importance of this public health responsibility as seen by organized medicine. Despite this and similar activities that have had modest success in presenting public information regarding the health consequences of tobacco use, the following facts are still with us: One thousand deaths per day in the United States are attributed to the effects of tobacco. There are 1 million new smokers per year in this country, the majority of whom represent young America. The Surgeon General continues to issue warnings regarding the urgency of this No. 1 public health problem. In excess of $2 billion is spent annually by the tobacco industry to promote their